Expanded Indications

March, 2008

The ability to treat painful degenerative conditions of the lumbar spine continues to improve and evolve as the patho-anatomy and patho-physiology of back and leg pain are further elucidated from Dr. Yeung’s continued experience with the YESS technique for selective endoscopic discectomy™. In highly selected patients, Dr. Yeung has successfully treated many patients with degenerative conditions such as central and lateral spinal stenosis, degenerative spondylolisthesis, and failed back surgery syndrome from recurrent disc herniations or lateral recess stenosis.

  • Evolving Foraminal Endoscopic Surgical Techniques and New Instrumentation

    The original YESS technique has been modified to approach the foramen using a more lateral approach to allow greater access to the epidural space and to enter a plane between the longissimus muscle and the psoas muscle. The advantage is that this plane avoids dilation of muscle and makes the procedure even less invasive. Approaching the foramen far laterally is also the same approach used for diagnostic and therapeutic injections that can be performed prior to the actual surgery to provide additional information and to give a more accurate prognosis for treatment of a wider spectrum of painful degenerative conditions of the lumbar spine.

  • Incorporating Diagnostic and Therapeutic Injection Techniques: YESS Approach

    These degenerative spinal conditions are first evaluated by transforaminal epidural injections using a non-ionic contrast agent such as ISO-VUE_300 to outline the foraminal anatomy, then therapeutically injecting a steroid such as Celestone soluspan mixed with .25% marcaine. If the surgeon can determine the probable cause of your pain and also determine that it is feasible to safely enter the foramen with the YESS surgical system to surgically address the condition, he may then be able to offer alternatives to more invasive surgical treatment, non surgical treatment, pain management treatment, traditional decompression and fusion, or dynamic stabilization that is available through most pain management and traditionally trained spine surgeons. As an alternative to decompression and fusion, Dr. Yeung performs a minimally invasive endoscopic foraminal decompression of the lateral facet, the foraminal osteophytes or the soft tissue like the ligamentum flavum contributing to the impingement on your traversing and exiting nerve. In chronic back pain, some of the nerves to the facet and disc annulus are also ablated, thus giving relief for back pain. This procedure can be compared to an arthroscopic debridement of a degenerative knee joint for pain relief before the joint wears out to the point of a knee replacement. Ultimately, as we age, a nucleus, facet, disc replacement, or even fusion may still be needed.

  • Endoscopic Medial Branch and Dorsal Ramus Rhizotomy

    If you have predominantly back pain and very little or no leg pain, a newly developed and simpler procedure called endoscopic medial and lateral branch and dorsal ramus rhizotomy may be able to reduce your chronic back pain, especially if this is accompanied by frequent episodes of involuntary back spasms with lists to the right or left. The approach is in a plane between the multifidus and longissimus muscle, directed to the transverse process where the medial branch of the Dorsal Ramus crosses the transverse process to go to the facet joint at and below the level of the lumbar disc space. Radio-frequency is used to ablate the nerve branches responsible for facet and disc annulus pain. With a visualized approach, the lateral branch of the dorsal ramus and even the dorsal ramus itself can be ablated. The procedure is called endoscopic medial branch and dorsal ramus rhizotomy, a procedure developed by Dr. Yeung. So far, the procedure has been effective 90% of the time in patients who benefit from medial branch blocks and elect to have the procedure.

    The traditional standard pain management techniques were modified by Dr. Yeung to utilize the endoscope for visualized treatment of these traditionally fluoroscopically guided procedures, making it more effective. Although complications are possible and anticipated in all surgical procedures, no neuromas or surgical complications have occurred in over 100 procedures. But 10% have had the pain return, presumable because of continued degeneration in the spine or re- nervation after nerve ablation.

  • Possible Adverse Events and Complications

    In the process of performing the foraminal decompression, Dr. Yeung has also found anomalous nerve branches in the foramen called furcal nerves. He has even found sympathetic nerve trunks in the foramen. If this is contributing to your pain syndrome, the surgical result is less predictable, and it is possible that these nerves will continue to give you the same, worse, or may create a different pain that is described as a dysesthetic pain. Most dysesthetic pain is relieved with time, and lessened if treated with transforaminal epidural steroid injections and sympathetic lumbar injections.

    It is not possible to avoid these nerves completely in foraminal decompression. If ablated, it can provide pain relief, dysesthesia, delayed dysesthesia, weakness, or numbness. Most of these symptoms resolve, but permanent persistence is also a risk of surgery. Please review the risks and potential complications of the procedure, including foot drop.

    Dr. Yeung has published the evolution of the YESS technique in peer reviewed journals and spine book chapters. Due to the fact that very few surgeons are trained in the YESS technique, is not likely to be covered by HMOs, or any managed care plans without the specific authorization of the medical directors on a case- by case basis. Medicare does not pay for this procedure in an outpatient setting at this time, and is not likely to change their rules soon.

    The endoscopic procedures described are usually covered only by indemnity plans, third party liability insurance, Arizona Workman’s Comp , and if you have out of network benefits with your PPO.

    This technique is also not the same as the other endoscopic techniques described by others on the internet unless the surgeon is trained by Dr. Yeung and also uses the YESS system.
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